Structured Assessment and Standards for Health Service in Wales
Structured Assessment is a self-assessment of the Health Board’s position in relation to the Governance and Accountability Module of the Standards for Health Services in Wales. The module on Governance and Accountability provides a framework for the Health Board to self-assess how well the organisation is governed, this being a fundamental factor in the provision of safe and effective care. It is also useful in demonstrating how we ensure the Health Board is fit for purpose.
A summary of the Board’s corporate level assessment of its governance arrangements using the Governance and Accountability module matrix is a Welsh Government requirement for inclusion in the Annual Governance Statement.
The Health Board must produce an Annual Governance Statement available here under Accountability Report 2018-19. This statement reflects the Health Board's governance, risk management and internal control arrangements and how they operate in practice. The statement reflects the Health Board's governance procedures and systems and is a product of the control framework.
Caldicott Principles in Practice (CPiP)
Caldicott Assessments and Improvement Plan
Since the Caldicott Report, regarding confidentiality in the NHS, was published in 1997 by Dame Fiona Caldicott, there have been significant changes to both Legislation and Codes of Practice which govern access to and use of patient identifiable information.
Implementation of the Caldicott Report recommendations commenced across NHS Wales in 1999 with the expectation that all health organisations would embark on a programme of continuous improvement of the organisation’s status against the Caldicott Principles.
In 2008, Informing Healthcare embarked on a review of the Caldicott Manual and in November launched the Foundation Manual for Caldicott Guardians, Caldicott Leads and Information Governance Leads. This manual provides all involved with protecting and using patient identifiable information with a knowledge framework with what they need to know, why they need to do it and how to do it. It also includes an online Self Assessment tool (C-PIP Assessment) which enables organisations to quickly evaluate where they are with compliance and plan improvement. This is the fifth annual assessment completed by Swansea Bay UHB.
The Caldicott Foundation Manual: Principles into Practice (C-PIP) provides Guardians and their support staff with updated knowledge about the legal background to their duties and aspects of Information Governance. The manual sets out what organisations need to do and the arrangements that need to be in place to ensure patient information is handled appropriately. The C-PIP Assessment consists of 41 Self Assessment standards which have been grouped into six sections. Against each question there is a hierarchy of answers that depending on which option is selected will automatically generate a score. Each organisation must then annually assess their compliance with the Caldicott Principles and produce a programme of work and continual improvement.
Swansea Bay UHB has completed the self assessment and the results are available on request.
The Health Board is monitored and scrutinised by a number of external bodies in regard to its performance in a variety of areas. Audit reports generated from these reviews will be considered by the Board or one of the Board Committees (usually Audit Committee).
Healthcare Inspectorate Wales (HIW) is the independent inspectorate and regulator of all health care in Wales. HIW’s core role is to review and inspect NHS and independent healthcare organisations in Wales to provide independent assurance for patients, the public, the Welsh Government and healthcare providers, that services are safe and good quality. HIW Reports on Swansea Bay University Health Board are on the HIW website.
Service User Surveys
The Health Board is committed to ensuring the continual improvement in the services that it provides and therefore intends to undertake service users’ surveys to obtain feedback about these services. Information relating to these surveys will be published on this website in due course.
Privacy Impact Assessments
Privacy impact assessments (PIAs) are a tool which can help organisations identify the most effective way to comply with their data protection obligations and meet individuals’ expectations of privacy. Information relating to PIAs will be published on this website in due course.